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Kletzer J, Scharinger B, Demirel O, Kaufmann R, Medved M, Reiter C, Hammerer M, Steinwender C, Hecht S, Kopp K, Hoppe UC, Hergan K, Boxhammer E. Radiological Parameters for the Detection of Pulmonary Hypertension in Severe Aortic Valve Stenosis and Their Influence on Mortality: Does Sex Matter? J Clin Med 2024; 13:1999. [PMID: 38610764 PMCID: PMC11012803 DOI: 10.3390/jcm13071999] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2024] [Revised: 03/11/2024] [Accepted: 03/22/2024] [Indexed: 04/14/2024] Open
Abstract
Background: Echocardiography has long been established as the primary noninvasive method for diagnosing pulmonary hypertension (PH) prior to transcatheter aortic valve replacement (TAVR) in patients with severe aortic valve stenosis (AS). In recent years, radiological methods for diagnosing PH have been investigated. Measurements such as the computed tomography angiography (CTA)-derived pulmonary artery (PA) diameter and PA diameter/body surface area (PA/BSA) have shown promising results regarding their diagnostic strength. However, it has yet to be determined if a patient's sex has any impact on the effectiveness of these diagnostic measurements. Methods: In all, 271 patients (51.3% male, mean age 82.6 ± 4.8 years) with severe AS undergoing TAVR were separated into male and female groups. The cut-off values for the diagnosis of PH were calculated for the CTA-derived PA diameter and PA/BSA based on different systolic pulmonal artery pressure values (40-45-50 mmHg). Patients were then subclassified according to measurements above or below these PA diameters and PA/BSA cut-off values. A PA diameter ≥29.5 mm and PA/BSA ≥ 15.7 mm/m2 qualified for PH. The 1-5 year survival rate in these cohorts was further analyzed. Results: Patients with a PA diameter ≥29.5 mm showed a significantly higher 1 year mortality rate (p = 0.014). This observation could only be confirmed for the male sex (p = 0.018) and not for the female sex (p = 0.492). As for the PA/BSA, in patients over the cut-off value, no significant increase in mortality was noted in the overall cohort. However, the male patients showed increased 3 year (p = 0.048) and 5 year mortality rates (p = 0.033). Conclusions: The CTA-obtained PA diameter and PA/BSA are both useful in the diagnosis of PH and mortality risk stratification in patients with severe AS undergoing TAVR, especially in males. Male patients with PA ≥ 29.5 mm or PA/BSA ≥ 15.7 mm/m2 seem to be at a higher risk of death during follow-up after undergoing TAVR. In females, no such correlation was observed.
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Affiliation(s)
- Joseph Kletzer
- Department of Internal Medicine II, Division of Cardiology, Paracelsus Medical University of Salzburg, 5020 Salzburg, Austria
| | - Bernhard Scharinger
- Department of Radiology, Paracelsus Medical University of Salzburg, 5020 Salzburg, Austria
| | - Ozan Demirel
- Department of Internal Medicine II, Division of Cardiology, Paracelsus Medical University of Salzburg, 5020 Salzburg, Austria
| | - Reinhard Kaufmann
- Department of Radiology, Paracelsus Medical University of Salzburg, 5020 Salzburg, Austria
| | - Michaela Medved
- Department of Radiology, Paracelsus Medical University of Salzburg, 5020 Salzburg, Austria
| | - Christian Reiter
- Department of Cardiology, Kepler University Hospital, Medical Faculty of the Johannes Kepler University Linz, 4040 Linz, Austria
| | - Matthias Hammerer
- Department of Internal Medicine II, Division of Cardiology, Paracelsus Medical University of Salzburg, 5020 Salzburg, Austria
| | - Clemens Steinwender
- Department of Cardiology, Kepler University Hospital, Medical Faculty of the Johannes Kepler University Linz, 4040 Linz, Austria
| | - Stefan Hecht
- Department of Radiology, Paracelsus Medical University of Salzburg, 5020 Salzburg, Austria
| | - Kristen Kopp
- Department of Internal Medicine II, Division of Cardiology, Paracelsus Medical University of Salzburg, 5020 Salzburg, Austria
| | - Uta C. Hoppe
- Department of Internal Medicine II, Division of Cardiology, Paracelsus Medical University of Salzburg, 5020 Salzburg, Austria
| | - Klaus Hergan
- Department of Radiology, Paracelsus Medical University of Salzburg, 5020 Salzburg, Austria
| | - Elke Boxhammer
- Department of Internal Medicine II, Division of Cardiology, Paracelsus Medical University of Salzburg, 5020 Salzburg, Austria
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Kletzer J, Hecht S, Ramsauer S, Scharinger B, Kaufmann R, Kammler J, Kellermair J, Akbari K, Blessberger H, Steinwender C, Hergan K, Hoppe UC, Lichtenauer M, Boxhammer E. A Story of PA/BSA and Biomarkers to Diagnose Pulmonary Hypertension in Patients with Severe Aortic Valve Stenosis-The Rise of IGF-BP2 and GDF-15. J Cardiovasc Dev Dis 2023; 10:jcdd10010022. [PMID: 36661917 PMCID: PMC9864369 DOI: 10.3390/jcdd10010022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2022] [Revised: 12/30/2022] [Accepted: 01/02/2023] [Indexed: 01/09/2023] Open
Abstract
(1) Background: Currently, echocardiography is the primary non-invasive diagnostic method used to screen patients with severe aortic valve stenosis (AS) for pulmonary hypertension (PH) by estimating systolic pulmonary artery pressure (sPAP). Other radiological methods have been a focus of research in the past couple of years, as it was shown that by determining the pulmonary artery (PA) diameter, prognostic statements concerning overall mortality could be made in these patients. This study compared established and novel cardiovascular biomarkers with the PA/BSA value to detect PH in patients with severe AS. (2) Methods: The study cohort comprised 188 patients with severe AS undergoing transcatheter aortic valve replacement (TAVR), who were then divided into two groups based on PA/BSA values obtained through CT-angiography. The presence of PH was defined as a PA/BSA ≥ 16.6 mm/m2 (n = 81), and absence as a PA/BSA < 16.6 mm/m2 (n = 107). Blood samples were taken before TAVR to assess cardiovascular biomarkers used in this study, namely brain natriuretic peptide (BNP), cardiac troponin I (cTnI), high-sensitive troponin (hsTN), soluble suppression of tumorigenesis-2 (sST2), growth/differentiation factor 15 (GDF-15), heart-type fatty acid-binding protein (H-FABP), insulin-like growth factor binding protein 2 (IGF-BP2), and soluble urokinase-type plasminogen activator receptor (suPAR). (3) Results: Patients with a PA/BSA ≥ 16.6 mm/m2 showed significantly higher levels of BNP (p = <0.001), GDF-15 (p = 0.040), and H-FABP (p = 0.007). The other investigated cardiovascular biomarkers did not significantly differ between the two groups. To predict a PA/BSA ≥ 16.6 mm/m2, cut-off values for the biomarkers were calculated. Here, GDF-15 (p = 0.029; cut-off 1172.0 pg/mL) and BNP (p < 0.001; cut-off 2194.0 pg/mL) showed significant results. Consequently, analyses of combined biomarkers were performed, which yielded IGF-BP2 + BNP (AUC = 0.721; 95%CI = 0.585−0.857; p = 0.004) as the best result of the two-way analyses and GDF-15 + IGF-BP2 + BNP (AUC = 0.727; 95%CI = 0.590−0.864; p = 0.004) as the best result of the three-way analyses. No significant difference regarding the 1-year survival between patients with PA/BSA < 16.6 mm/m2 and patients with PA/BSA ≥ 16.6 mm/m2 was found (log-rank test: p = 0.452). (4) Conclusions: Although PA/BSA aims to reduce the bias of the PA value caused by different body compositions and sizes, it is still a controversial parameter for diagnosing PH. Combining the parameter with different cardiovascular biomarkers did not lead to a significant increase in the diagnostic precision for detecting PH in patients with severe AS.
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Affiliation(s)
- Joseph Kletzer
- Department of Internal Medicine II, Division of Cardiology, Paracelsus Medical University of Salzburg, 5020 Salzburg, Austria
| | - Stefan Hecht
- Department of Radiology, Paracelsus Medical University of Salzburg, 5020 Salzburg, Austria
| | - Susanne Ramsauer
- Department of Internal Medicine II, Division of Cardiology, Paracelsus Medical University of Salzburg, 5020 Salzburg, Austria
| | - Bernhard Scharinger
- Department of Radiology, Paracelsus Medical University of Salzburg, 5020 Salzburg, Austria
| | - Reinhard Kaufmann
- Department of Radiology, Paracelsus Medical University of Salzburg, 5020 Salzburg, Austria
| | - Jürgen Kammler
- Department of Cardiology, Kepler University Hospital, Medical Faculty of the Johannes Kepler University Linz, 4020 Linz, Austria
| | - Jörg Kellermair
- Department of Cardiology, Kepler University Hospital, Medical Faculty of the Johannes Kepler University Linz, 4020 Linz, Austria
| | - Kaveh Akbari
- Department of Radiology, Johannes Kepler University Hospital Linz, 4020 Linz, Austria
| | - Hermann Blessberger
- Department of Cardiology, Kepler University Hospital, Medical Faculty of the Johannes Kepler University Linz, 4020 Linz, Austria
| | - Clemens Steinwender
- Department of Cardiology, Kepler University Hospital, Medical Faculty of the Johannes Kepler University Linz, 4020 Linz, Austria
| | - Klaus Hergan
- Department of Radiology, Paracelsus Medical University of Salzburg, 5020 Salzburg, Austria
| | - Uta C. Hoppe
- Department of Internal Medicine II, Division of Cardiology, Paracelsus Medical University of Salzburg, 5020 Salzburg, Austria
| | - Michael Lichtenauer
- Department of Internal Medicine II, Division of Cardiology, Paracelsus Medical University of Salzburg, 5020 Salzburg, Austria
| | - Elke Boxhammer
- Department of Internal Medicine II, Division of Cardiology, Paracelsus Medical University of Salzburg, 5020 Salzburg, Austria
- Correspondence:
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Boxhammer E, Scharinger B, Kaufmann R, Brandtner H, Schmidbauer L, Kammler J, Kellermair J, Reiter C, Akbari K, Hammerer M, Blessberger H, Steinwender C, Hergan K, Hoppe UC, Lichtenauer M, Hecht S. Comparability between Computed Tomography Morphological Vascular Parameters and Echocardiography for the Assessment of Pulmonary Hypertension in Patients with Severe Aortic Valve Stenosis-Results of a Multi-Center Study. Diagnostics (Basel) 2022; 12:diagnostics12102363. [PMID: 36292052 PMCID: PMC9600691 DOI: 10.3390/diagnostics12102363] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2022] [Revised: 09/23/2022] [Accepted: 09/26/2022] [Indexed: 12/03/2022] Open
Abstract
Background: Computed tomography (CT) of the aorta and cardiac vessels, which is performed in patients with severe aortic valve stenosis (AS) before transcatheter aortic valve replacement (TAVR), offers the possibility of non-invasive detection of pulmonary hypertension (PH), for example, by determining the diameter of the main pulmonary artery (PA), the right pulmonary artery (RPA) or the left pulmonary artery (LPA). An improvement of the significance of these radiological parameters is often achieved by indexing to the body surface area (BSA). The aim of this study was to compare different echocardiographic systolic pulmonary artery pressure (sPAP) values with radiological data in order to define potential clinical cut-off values for the presence or absence of PH. Methods: A total of 138 patients with severe AS undergoing TAVR underwent pre-interventional transthoracic echocardiography with determination of sPAP values and performance of CT angiography (CTA) of the aorta and femoral arteries. Radiologically, the PA, RPA, LPA, and ascending aorta (AA) diameters were obtained. Vascular diameters were not only indexed to BSA but also ratios were created with AA diameter (for example PA/AA-ratio). From these CT-derived vascular parameters, AUROC curves were obtained regarding the prediction of different sPAP values (sPAP 40−45−50 mmHg) and finally correlation analyses were calculated. Results: The best AUROC and correlation analyses were generally obtained at an sPAP ≥ 40 mmHg. When considering diameters alone, the PA diameter was superior to the RPA and LPA. Indexing to BSA generally increased the diagnostic quality of the parameters, and finally, in a synopsis of all results, PA/BSA had the best AUC 0.741 (95% CI 0.646−0. 836; p < 0.001; YI 0.39; sensitivity 0.87; specificity 0.52) and Spearman’s correlation coefficient (r = 0.408; p < 0.001) at an sPAP of ≥40 mmHg. Conclusions: Features related to pulmonary hypertension are fast and easily measurable on pre-TAVR CT and offer great potential regarding non-invasive detection of pulmonary hypertension in patients with severe AS and can support the echocardiographic diagnosis. In this study, the diameter of the main pulmonary artery with the additionally determined ratios were superior to the values of the right and left pulmonary artery. Additional indexing to body surface area and thus further individualization of the parameters with respect to height and weight can further improve the diagnostic quality.
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Affiliation(s)
- Elke Boxhammer
- Department of Internal Medicine II, Division of Cardiology, Paracelsus Medical University of Salzburg, Müllner Hauptstraße 48, 5020 Salzburg, Austria
- Correspondence: (E.B.); (S.H.)
| | - Bernhard Scharinger
- Department of Radiology, Paracelsus Medical University of Salzburg, 5020 Salzburg, Austria
| | - Reinhard Kaufmann
- Department of Radiology, Paracelsus Medical University of Salzburg, 5020 Salzburg, Austria
| | - Herwig Brandtner
- Department of Radiology, Paracelsus Medical University of Salzburg, 5020 Salzburg, Austria
| | - Lukas Schmidbauer
- Department of Internal Medicine II, Division of Cardiology, Paracelsus Medical University of Salzburg, Müllner Hauptstraße 48, 5020 Salzburg, Austria
| | - Jürgen Kammler
- Department of Cardiology, Kepler University Hospital, Medical Faculty of the Johannes Kepler University Linz, 4020 Linz, Austria
| | - Jörg Kellermair
- Department of Cardiology, Kepler University Hospital, Medical Faculty of the Johannes Kepler University Linz, 4020 Linz, Austria
| | - Christian Reiter
- Department of Cardiology, Kepler University Hospital, Medical Faculty of the Johannes Kepler University Linz, 4020 Linz, Austria
| | - Kaveh Akbari
- Department of Radiology, Johannes Kepler University Hospital Linz, 4020 Linz, Austria
| | - Matthias Hammerer
- Department of Internal Medicine II, Division of Cardiology, Paracelsus Medical University of Salzburg, Müllner Hauptstraße 48, 5020 Salzburg, Austria
| | - Hermann Blessberger
- Department of Cardiology, Kepler University Hospital, Medical Faculty of the Johannes Kepler University Linz, 4020 Linz, Austria
| | - Clemens Steinwender
- Department of Cardiology, Kepler University Hospital, Medical Faculty of the Johannes Kepler University Linz, 4020 Linz, Austria
| | - Klaus Hergan
- Department of Radiology, Paracelsus Medical University of Salzburg, 5020 Salzburg, Austria
| | - Uta C. Hoppe
- Department of Internal Medicine II, Division of Cardiology, Paracelsus Medical University of Salzburg, Müllner Hauptstraße 48, 5020 Salzburg, Austria
| | - Michael Lichtenauer
- Department of Internal Medicine II, Division of Cardiology, Paracelsus Medical University of Salzburg, Müllner Hauptstraße 48, 5020 Salzburg, Austria
| | - Stefan Hecht
- Department of Radiology, Paracelsus Medical University of Salzburg, 5020 Salzburg, Austria
- Correspondence: (E.B.); (S.H.)
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Boxhammer E, Berezin AE, Paar V, Bacher N, Topf A, Pavlov S, Hoppe UC, Lichtenauer M. Severe Aortic Valve Stenosis and Pulmonary Hypertension: A Systematic Review of Non-Invasive Ways of Risk Stratification, Especially in Patients Undergoing Transcatheter Aortic Valve Replacement. J Pers Med 2022; 12:jpm12040603. [PMID: 35455719 PMCID: PMC9026430 DOI: 10.3390/jpm12040603] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2022] [Revised: 04/01/2022] [Accepted: 04/04/2022] [Indexed: 02/01/2023] Open
Abstract
Patients with severe aortic valve stenosis and concomitant pulmonary hypertension show a significantly reduced survival prognosis. Right heart catheterization as a preoperative diagnostic tool to determine pulmonary hypertension has been largely abandoned in recent years in favor of echocardiographic criteria. Clinically, determination of echocardiographically estimated systolic pulmonary artery pressure falls far short of invasive right heart catheterization data in terms of accuracy. The aim of the present systematic review was to highlight noninvasive possibilities for the detection of pulmonary hypertension in patients with severe aortic valve stenosis, with a special focus on cardiovascular biomarkers. A total of 525 publications regarding echocardiography, cardiovascular imaging and biomarkers related to severe aortic valve stenosis and pulmonary hypertension were analyzed in a systematic database analysis using PubMed Central®. Finally, 39 publications were included in the following review. It was shown that the current scientific data situation, especially regarding cardiovascular biomarkers as non-invasive diagnostic tools for the determination of pulmonary hypertension in severe aortic valve stenosis patients, is poor. Thus, there is a great scientific potential to combine different biomarkers (biomarker scores) in a non-invasive way to determine the presence or absence of PH.
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Affiliation(s)
- Elke Boxhammer
- Department of Internal Medicine II, Division of Cardiology, Paracelsus Medical University of Salzburg, 5020 Salzburg, Austria; (E.B.); (V.P.); (N.B.); (A.T.); (U.C.H.)
| | - Alexander E. Berezin
- Internal Medicine Department, State Medical University of Zaporozhye, 69035 Zaporozhye, Ukraine;
| | - Vera Paar
- Department of Internal Medicine II, Division of Cardiology, Paracelsus Medical University of Salzburg, 5020 Salzburg, Austria; (E.B.); (V.P.); (N.B.); (A.T.); (U.C.H.)
| | - Nina Bacher
- Department of Internal Medicine II, Division of Cardiology, Paracelsus Medical University of Salzburg, 5020 Salzburg, Austria; (E.B.); (V.P.); (N.B.); (A.T.); (U.C.H.)
| | - Albert Topf
- Department of Internal Medicine II, Division of Cardiology, Paracelsus Medical University of Salzburg, 5020 Salzburg, Austria; (E.B.); (V.P.); (N.B.); (A.T.); (U.C.H.)
| | - Sergii Pavlov
- Department of Clinical Laboratory Diagnostics, State Medical University of Zaporozhye, 69035 Zaporozhye, Ukraine;
| | - Uta C. Hoppe
- Department of Internal Medicine II, Division of Cardiology, Paracelsus Medical University of Salzburg, 5020 Salzburg, Austria; (E.B.); (V.P.); (N.B.); (A.T.); (U.C.H.)
| | - Michael Lichtenauer
- Department of Internal Medicine II, Division of Cardiology, Paracelsus Medical University of Salzburg, 5020 Salzburg, Austria; (E.B.); (V.P.); (N.B.); (A.T.); (U.C.H.)
- Correspondence:
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